Nursing Process Practice Questions

Correct Answer: D

Rationale: The correct answer is D: Pallor, tachycardia, and a sore tongue. Pernicious anemia is caused by a deficiency in vitamin B12, leading to symptoms such as pallor (due to decreased red blood cells), tachycardia (as the heart works harder to compensate for decreased oxygen-carrying capacity of the blood), and a sore tongue (due to inflammation of the tongue). Choice A is incorrect because bradycardia would not be expected in pernicious anemia, and reduced pulse is not a typical finding. Choice B is incorrect because weight gain is not a common symptom of pernicious anemia. Choice C is incorrect because angina and double vision are not typical findings of pernicious anemia, and anorexia is more likely due to other causes.

Correct Answer: A

Rationale: The correct answer is A: Detects the presence of malignant cells. Biopsy involves taking a sample of tissue to examine under a microscope for the presence of abnormal or cancerous cells. This procedure is crucial for diagnosing cancer accurately. Choice B (Measures hemoglobin content) is incorrect because hemoglobin content is typically measured through blood tests, not biopsies. Choice C (Measures the RBC size) is incorrect as RBC size is usually assessed through a complete blood count (CBC) test, not a biopsy. Choice D (Detects arterial occlusion) is incorrect because arterial occlusion is typically diagnosed through imaging studies like Doppler ultrasound or angiography, not through a biopsy procedure.

Correct Answer: A

Rationale: The correct answer is A: It inhibits deoxyribonucleic acid (DNA) synthesis. Mitomycin works by cross-linking DNA, leading to inhibition of DNA synthesis and ultimately causing cell death. This mechanism of action makes it effective against rapidly dividing cancer cells. B: It�s cell cycle-phase specific - This is incorrect because mitomycin is not specific to a particular phase of the cell cycle. C: It inhibits ribonucleic acid (RNA) synthesis - This is incorrect as mitomycin primarily targets DNA synthesis, not RNA synthesis. D: It inhibits protein synthesis - This is incorrect as mitomycin's main mechanism of action is through DNA cross-linking, not protein synthesis inhibition.

Correct Answer: A

Rationale: The correct answer is A: Ambulating a patient. Direct care interventions involve hands-on activities directly impacting patient outcomes. Ambulating a patient is a direct care intervention as it involves physically assisting the patient to move, promoting circulation, preventing complications, and improving overall well-being. Inserting a feeding tube (B) and performing resuscitation (C) are also direct care interventions as they involve immediate patient care actions. Documenting wound care (D) is not a direct care intervention as it involves recording information about a care activity rather than physically performing the care itself.

Correct Answer: D

Rationale: The correct answer is D because developing a standard formal nursing diagnosis helps nurses focus on the scope of their practice. By identifying specific patient problems and their potential causes, nurses can provide appropriate interventions and evaluate patient outcomes effectively. This process enhances the quality of care delivery and promotes patient safety. A: This is incorrect because nursing diagnoses are not meant to be a language exclusive to nurses but rather a standardized way to communicate patient data. B: This is incorrect as nursing diagnoses are not about distinguishing roles but rather about identifying and addressing patient problems. C: This is incorrect as nursing diagnoses are based on evidence and critical thinking, not solely on intuition.